Dyck Insurance

Name: *

Email Address: *

Phone Number: *

Your Age: *

Address: *

City: *

Province: *

Postal Code: *

M1 License Date: *

M2 License Date:

M3 License Date:

What Coverage are you looking for?: All Perils Collision Comprehensive Specified Perils *

Liability Limit: $1,000,000 $2,000,000 $5,000,000 *

Collision Deductible amount: $100 $250 $500 $1000 *

Comprehensive Deductible amount: $100 $250 $500 $1000 *

Specified Perils Deductible amount: $100 $250 $500 $1000 *

Year, make and model: *

Number of CC's *

Value of Bike: *

Previous Insurance Company: *

Do you have a class 6 motorcycle license? Yes No *

How many years have you had a class 6 license? *

Did you take a Riders Training Course?: Yes No *

Modified or Customized: Yes No *

Do you belong to any Riders Associations or Clubs?: Yes No *

Any Tickets?: Yes No *

Any claims in last 6 years?: Yes No *